Mental health crisis: CMS issues proposals to help psychologists meet the demand

The Centers for Medicare and Medicaid Services (CMS) has released the proposed rule on the 2023 Medicare physician fee schedule containing several proposals that would increase beneficiary access to mental and behavioral health. 

Key areas addressed in the proposed rule include:

• Expanding telehealth services.
• Reimbursing psychologists for integrated care services.
• Relaxing the supervision requirements for “incident to” services.
• Potential new billing codes for caregiver training, chronic pain management, and various underutilized services.
• Reporting under the Quality Payment Program.

APA Services, Inc. will send comments to the agency discussing the issues outlined below, as well as additional changes included in the proposed rule.

After reading through this analysis of the proposed rule, APA Services encourages all psychologists to take action and share their thoughts on the proposals with CMS. The easiest way to make your voice heard is through the APA Action Centeropens in new window. Comments must be submitted to CMS by September 6, 2022.

Payment policies are always included in the annual proposed rule. For 2023, CMS is projecting the conversion factor, a number used to convert relative value units for each billing code into dollars, to be $33.08. This translates to a 4.4% decrease from the current $34.61 conversion factor. Taking into consideration the many factors that make up the Medicare payment formula, CMS estimates the combined impact on psychologists’ payment in 2023 will be a 2% loss from 2022.

Much of the reduction is due to the year-end expiration of changes implemented under previous legislation. APA Services will advocate to Congress for new legislation to protect psychologists from suffering this loss in payment. APA’s Advocacy Office will provide information on how psychologists can help deliver this message.

APA Services will continue to ask CMS to refrain from returning to its prepandemic practice of reimbursing for telehealth services at the facility rate once the public health emergency waivers end. Psychologists providing telehealth services from their offices are incurring at least the same and sometimes more expenses as they do when furnishing in-person services. CMS must understand that they cannot expect increased access to mental and behavioral health services if they do not adequately reimburse psychologists for providing these critical services.

CMS is proposing to add more services to Medicare’s temporary (Category 3) list for telehealth. APA Services supports the addition of codes for developmental testing (96112–13), brief assessment (96127), health behavior assessment and intervention for family without the patient (96170–71), therapeutic intervention for cognitive function (97129–30), and adaptive behavior assessment (97151, 97152, 0362T) and treatment (97153, 97154, 97155, 97156, 97157, 97158, 0373T) codes. Services previously added to Category 3 will remain on the Medicare telehealth list until December 31, 2023.

In the proposed rule, CMS cites APA studies on the increase in demand for mental health services in 2020 and 2021. To help meet this demand, CMS has proposed several regulatory changes that will make it easier for patients to access mental and behavioral health services provided by masters’-level practitioners and in integrated care settings.

The first proposed change—an amendment to the “incident to” requirements—would allow psychologists and physicians to provide general supervision and bill for services by licensed providers who cannot independently bill Medicare, such as licensed professional counselors or marriage and family therapists.

The current “incident to” policy only allows reimbursement for direct supervision, which requires that the physician or nonphysician practitioner (NPP) be located within the same office suite as the auxiliary staff performing the service. Under general supervision, the service is provided under the physician or NPP’s direction and control but does not require their physical presence.

APA Services applauds CMS’ proposed revisions to the “incident to” physicians’ services regulation for behavioral health services. Psychologists regularly collaborate with other mental health specialists as part of a patient’s treatment team and are well-suited to supervise masters’-level practitioners. APA Services believes this will help expand access to, and coordination of, mental health services in rural and underserved areas where masters’-level practitioners represent a substantial segment of the mental health providers in the area.

APA Services is also asking CMS to allow licensed psychologists to report the services of advanced psychology trainees under their supervision, a practice allowed by many state Medicaid programs. Although clinical psychology interns typically receive 1,000–2,000 hours of clinical experience prior to beginning their internship, services provided by trainees under the supervision of a licensed psychologist are not reimbursable under Medicare. Without Medicare reimbursement of services provided by trainees, training programs are left without a steady source of funding.

To promote psychologists’ work within integrated care, the agency has also proposed creating a new Healthcare Common Procedure Coding System (HCPCS) code, GBHI1.

This new code describes general behavioral health integration services, performed by clinical psychologists or clinical social workers, who serve as the focal point of care integration, and would capture 20 or more minutes of the clinician’s time each month. Additionally, psychologists can report services completed by other members of the team and report them as “incident to” the treating provider.

APA Services supports CMS’ establishment of a new coding and payment for General Behavioral Health Integration to recognize psychologists’ role in facilitating integrated care. Many psychologists practice within an integrated approach to treatment that addresses a patient’s primary care needs and behavioral health needs under one roof, resulting in better patient outcomes, improved coordination of care, and increased patient satisfaction with treatment. APA Services appreciates that CMS is supporting multiple evidence-based models of integrated care, as it allows psychologists the flexibility they require to support the behavioral health needs of the broader community.

There will be a new base and add-on code pair to describe multifamily group caregiver behavior management training in 2023.

Unfortunately, CMS has determined that this service will not be paid by Medicare because they view the services as benefiting caregivers but not patients. The agency is asking for comments on how patients could benefit from caregiver management behavior training.

APA Services developed these codes and will be advocating that the codes would benefit the patient and should be reimbursed. There is extensive empirical support for caregiver behavior management training, and it is the gold standard treatment approach for several mental and health behavior issues. These codes are meant to teach the patient’s parent or caregiver evidence-based interventions and strategies that they can use in their daily management of the patient’s mental and health behavior issue. Although the patient is not present when this training is provided, these codes directly benefit the patient. The clinical benefits of caregiver behavior management training include: reduction in disruptive and problematic behaviors for children with ADHD, improved weight management for individuals with obesity, and better management of patients with dementia.

CMS is proposing a new Chronic Pain Management and Treatment bundle which would include a new base and add-on HCPCS code pair for reporting these services. However, APA Services is concerned that psychologists, who play a critical role in implementing nonpharmacological approaches to treatment as well as team-based comprehensive pain management, would be excluded from reimbursement under this new bundled service because of the emphasis on medication management.

Pain is widely recognized as a biopsychosocial phenomenon. APA Services appreciates CMS’ consideration of new ways to increase access to chronic pain management that lowers the risk of the development of opioid use disorders and substance abuse.

Still, APA Services is asking CMS to create additional bundled pain management codes that do not include medication management. Psychologists are actively involved in pain management and provide nearly all the services included in the new bundled service, except medication management. Additional bundled codes that do not include medication management will provide greater flexibility in treatment and allow psychologists to provide pain management services and practice to the top of their license when participating in team-based comprehensive chronic pain treatment.

APA Services will ask CMS to create new codes for Cognitive Assessment and Care services without medication reconciliation as these are services frequently provided by neuropsychologists. APA Services will also ask that psychologists be reimbursed for Intensive Behavioral Therapy (IBT) for Obesity services.

APA Services appreciates CMS’ request for comments on potentially underutilized services, as several of the services CMS identified are performed by psychologists. APA Services recommends CMS create additional Cognitive Assessment and Care codes without the medication reconciliation service. Neuropsychologists are actively involved in cognitive assessment and provide all the services involved in the Cognitive Assessment and Care service, except for medication reconciliation. Because medication management is outside the scope of a psychologist’s license in many states, from a coding standpoint, neuropsychologists are currently unable to provide these services and practice to the top of their license.

Additionally, APA recommends CMS allow reimbursement for IBT for Obesity services provided by psychologists. To date the agency has limited IBT for obesity services to primary care providers, even though psychologists also provide these services.

APA Services strongly urges CMS to reconsider its approach to digital therapeutics reimbursement.

New technologies are an ever-expanding presence in mental health treatment and we appreciate CMS’ willingness to start a broader conversation about a reimbursement mechanism to allow access to evidence-based digital therapeutics. However, CMS’ proposal to fold these reimbursement codes into the Remote Therapeutic Monitoring (RTM) family of codes mischaracterizes what digital therapeutics do and how they are used.

APA Services previously submitted a proposal to CMS that would establish a new set of reimbursement codes for digital therapeutics—one for purchase of the device/software, one for initial patient education about the device/software, and two for ongoing management of the service furnished through the device or software. Unlike the RTM codes, this structure reimburses for an active therapeutic intervention, as opposed to passively monitoring a patient’s condition. Implementing a new set of reimbursement codes as outlined above will have a positive impact on access to treatment while ensuring the service is delivered under the supervision of a psychologist or other qualified health care provider.

Other CMS proposals supported by APA Services include:

• changing the codes for family psychotherapy with the patient (90847) and without the patient (90849) from restricted to active
• delaying the in-person requirement for 151 days for Rural Health Clinic and Federal Qualified Health Center mental health visits via telehealth
• adding modifier 93 for telehealth services furnished using audio-only devices.

APA Services supports the following proposals for the Merit-based Incentive Payment System (MIPS):

• Adding an Improvement Activity for planning to improve care for LGBTQ patients
• Reweighting the Promoting Interoperability Performance Category to zero for psychologists and certain other NPPs. APA Services also plans to argue the reweighting should continue past 2023
• Holding the MIPS performance threshold at 75 points and data completeness at 70% of eligible encounters
• Adding a telehealth indicator to public reporting. APA Services will recommend that CMS track Point of Service (POS) codes 02 and 10 as mental health providers will use both POS codes at various times

Take action by sharing your comments and concerns with CMS through the APA Action Centeropens in new window. Comments must be submitted to CMS by September 6, 2022.